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Electronic medication management (EMM) A guide for healthcare providers
V1.01 December 2015
Overview
Purpose of this guide Those viewing this presentation will come away knowing at a high level how electronic medication management (EMM) works and how it can support primary care, including GPs, pharmacies and residential aged care facilities. Those from the acute care sector will see a brief overview of how EMM systems support key activities and also how hospital systems will interact with primary care. Who should read this guide? This guide is intended for healthcare providers. It is not intended to provide detailed technical information.
How to read this guide This guide can be read in full, or browsed in parts by clicking the links to the sections you find most relevant. You’ll also find a ‘<< contents page’ link at the top of every slide.
EMM, a guide for healthcare providers 2
Contents
Introduction to electronic medication management (EMM) This section provides a brief overview of the concepts covered by electronic medication management.
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Why do we need EMM? What are the current problems with medicines management where technology can help?
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What are the safety benefits of EMM? EMM has been shown to be safer, more efficient and can help deliver improved clinical outcomes.
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How does EMM support the medicines management cycle? An overview of how EMM systems support QUM processes Page 10
What is happening Nationally? A summary of the national EMM activities in Australia. Page 36
Glossary of terms Page 28
EMM, a guide for healthcare providers 3
Introduction to electronic medication management (EMM) What is electronic medications management and why do we need it?
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Introduction to electronic medication management
Electronic medication management (EMM) is a broad term that incorporates any electronic clinical information system, tool or software application that is used to support the medicines management cycle. This includes:
Prescribing systems; such as GP desktop computers or hospital clinical information systems that have electronic ordering deployed.
Decision support systems; such as evidence based order-sets, allergy checking, drug interactions.
Dispensing systems; such as pharmacy software and automated dispensing systems.
Ordering and supply solutions; such as the electronic transfer of prescriptions (ETP) and hospital messaging solutions.
Administration records; such as electronic medication administration records.
This guide provides a high level overview of the current systems that are available, or being planned, and how they relate to practice.
EMM, a guide for healthcare providers 5
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Why do we need electronic medication management?
There are a number of drivers that highlight the need to utilise EMM systems. These include: • Improving the legibility of prescription orders to ensure that they are unambiguous
and easily understood. • Supporting clinicians with choosing appropriate and cost-effective treatments
and helping to reduce clinical variation. • Improving the accuracy and visibility of medication information being communicated
between professionals and health care providers. • Increasing the quality of information is available along the medicines management
pathway to ensure health providers and consumers have more complete information.
• Optimising the medicines supply chain to control costs and drive efficiencies.
Finally, EMM enables the increased sharing of information with consumers, their carers and other providers.
EMM, a guide for healthcare providers 6
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What are the safety benefits of electronic medications management?
EMM implementers cite numerous benefits from EMM systems, however the greatest anticipated benefit of implementing EMM are the reduction of preventable adverse drug events (ADEs) including:
• Fewer prescribing errors as EMM systems provide clinical decision support.
• Lower dispensing errors through closed-loop medication ordering, automation and barcode scanning.
• Reduced administration errors through clearer information on electronic medication administration records, reminders, safety alerts and administration barcode checking.
• Less omission and commission errors at transitions in care through improved transfer of information.
• Improved medication adherence and minimised misuse, over-use and under-use of medicines.
These safety benefits have been described by implementers as reducing the number of medicines related episodes of care, reducing readmissions and length of stay in hospitals.
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What does the evidence say?
Electronic medication management is an emerging field and the literature supporting its benefits is still growing. A number of key papers support the anticipated safety benefits of EMM.
Follow the links below to access some more relevant papers on the benefits of EMM.
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Effects of two commercial electronic prescribing systems on
prescribing error rates
Implementing electronic management at an Australian
teaching hospital
Errors and electronic prescribing: a controlled laboratory study to
examine task complexity and interruption effects
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How does EMM support the medicines management cycle? How EMM systems can support some of the key flows in medicines management
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EMM and the medicines management cycle
• The medications management cycle is a complex, continuous process involving many stakeholders including prescribers, dispensers, administrators and consumers.
• The continuous optimisation of the cycle, combined with the principle of Quality Use of Medicines are common goals of governments and health providers.
• The Commission has modified the cycle diagram from the National Medicines Policy to explain how EMM systems are being implemented to support the various stages in the process.
APAC 2005 Guiding principles to achieve continuity in medication management JULY 2005 http://www.health.gov.au/internet/main/publishing.nsf/Content/5B47B202BBFAFE02CA257BF0001C6AAC/$File/guiding.pdf
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electronic medication management in
practice
Click on a section to find out how EMM can support
this process
RECONCILIATION
PRESCRIBING
ORDER, RECORD & REVIEW
DISPENSING
SUPPLY OF MEDICINES
MEDICINES ADMINISTRATION
MONITOR FOR EFFECT OF MEDICINES
CONTINUITY OF CARE
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EMM in medicines reconciliation Overview
Medication reconciliation is a formal process of obtaining and verifying a complete and accurate list of each patient’s current medicines. Matching the medicines the patient should be prescribed to those they are actually prescribed.1 Medicines reconciliation is particularly important when care is transferred - when a patient is admitted to hospital, or transferred from hospital to the home. Common problems in medicines reconciliation • Between 10%-67% of medication histories have at least one error. • Up to one third of these errors have the potential to cause patient harm. • More than 50% of medication errors occur at transitions of care. • Patients with one or more medicines missing from their discharge information are 2.3 times
more likely to be readmitted to hospital than those with correct information on discharge. • 85% of discrepancies in medication treatment originate from poor medication history
taking. These educational materials provide clinicians with information on the four steps of the medication reconciliation process, evidence to support its use and the importance of team work and communication among staff involved in the patient’s care.
EMM, a guide for healthcare providers 12 1. ACSQHC website [http://www.safetyandquality.gov.au/our-work/medication-safety/medication-reconciliation/] accessed on 18th June 2015
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EMM systems can facilitate improved medicines history and medicines reconciliation through: • Access to more information sources that can help provide a clearer picture of a patient’s
current medicines, the diagram below describes how; • Tools and processes to facilitate workflows associated with medicines reconciliation.
EMM in medicines reconciliation Initiatives
Your own records
My Health Record
Secure messages
Patient/ carer
More complete medicines
info
Improving the quality of your patient
records by using the Australian Medicines
Terminology
Comparing your own records with My Health Record
documents including Shared health summaries,
prescription & dispense records
Receive electronic documents from other health providers with important medicines information such as
eReferrals, eDischarge summaries and specialist letters
There are a growing number of
Consumer Apps that now collect
information about current medicines including the NPS MedicineWise app
There are an increased number of data sources that can be used to provide up
to date medicines information for the purpose of reconciliation. A growing number of applications now have tools to support this
data collection
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EMM, a guide for healthcare providers
Health Providers can now send e-Referral documents via a secure messaging service to providers with the appropriate infrastructure and capacity. e-Referrals are a standard format that may include:
– details about the patient; – the reason for the referral; – current medications; – medical history; – adverse reactions; and – diagnostic investigations including pathology test results.
These documents provide very useful information resources that can be validated with patients in the process of medicines reconciliation.
The NEHTA website has more information about e-Referrals
EMM in medicines reconciliation The role of e-Referral < back
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Screenshot of a sample e-Referral
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EMM, a guide for healthcare providers
EMM, a guide for healthcare providers 15
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Next section
EMM in prescribing Overview
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The prescription of medication is one of the most common healthcare interventions made by health providers in both acute and primary care. Clinicians make a decision to provide treatment based on the information they have about the patient, their interpretation of the patients presenting compliant and diagnosis. They rely on access to the latest knowledge and guidelines, combined with their assessment of the patients needs in order to select the most appropriate medication. Common problems in prescribing • Increasing numbers of patients have co-morbidities and more and more Australians
are taking 4 or more medicines.(1)
• Medicines knowledge is increasing at a faster rate than it is possible for health providers to continually remain up-to-date.
• Only 57% of patients receive the appropriate treatment as per the relevant guidelines.(2)
Click here to find out how EMM systems can support prescribing
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1. Morgan T., Williamson M. et al. A national census of medicines use: a 24-hour snapshot of Australians aged 50 years and older MJA 2012; 196: 50-53
2. Runciman W., Hunt T., Hannaford N., et al;, CareTrack: assessing the appropriateness of health care delivery in Australia https://www.mja.com.au/journal/2012/197/2/caretrack-assessing-appropriateness-health-care-delivery-australia
EMM in prescribing Initiatives
Better prescribing
Clinical decision support
Better medicines histories
Consistent medicines
terminology
Closed loop medications
ordering
Exchange of medicines information
Improved health
information
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EMM; a Brief Guide for Health Providers 17
Clinical information systems are able to provide support for clinicians in making decisions on treatment choice, medicines selection and use with an increasing number of knowledge driven clinical decision support
solutions now available. The increased quality and completeness of a
consumers health information is a key enabler of clinical decision support
With more information available about current medicines through
documents in the My Health Record, such as: shared health
summaries, discharge summaries, prescription and dispense records
Consistent, unambiguous terminology and unique identifiers
by utilising the Australian Medicines Terminology (AMT) is a key enabler of better data quality, interoperability, clinical decision
support and other prescribing tools
In community, by sending prescriptions electronically through a Prescription Exchange Service or in Hospitals through integrated EMM
clinical systems
Through the sharing of prescription and dispense records with the My Health Record, or through secure messages of eDischarge
summaries and event summaries
More complete information, including allergies, previous
episodes of care and comorbidities is available
through shared records, the My Health Record and improved
clinical systems
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EMM, a guide for healthcare providers 18
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Next section
EMM in order, record & review Overview
Once a decision is taken to prescribe a medicine, the next step is to make an order. We’ve already discussed some of the steps taken in this process in the previous section. In a hospital, this might be the step where a pharmacist reviews and verifies the order before it is sent or on receipt to the pharmacy. In community this might be the receipt of a prescription or electronic prescription. The dispenser must now review the order, check its appropriateness and make a record against the patients record in their system. Common problems in order, record & review • Legibility issues with handwritten orders are still common in acute care. • Lack of information about the patients condition, co-morbidities or concurrent medicines. • Communication with prescribers for clarifications.
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EMM, a guide for healthcare providers
Electronic order entry Sent as an order direct
from the clinical information system
Guidelines
EMM in order, record & review Initiatives
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Alerts
Pharmacist verification In hospitals this might
be in your EMM system
Closed-loop dispensing
Automatic matching of orders with products in the dispensary system
Shared Electronic Medical Records
Prescription / dispense records in My Health Record
Closed-loop ordering, verification and dispensing. Enabled by standardised medicines terminology & unique identifiers
Records can be automatically sent to the My Health Record
Prescribing data stored in the medical records
Messages and notes
Order sets &
templates
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EMM in order, record & review Electronic transfer of prescriptions (ETP)
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Prescription exchange service
eRX or MediSecure allow for prescriptions to be sent securely and
electronically between GPs and pharmacies.
Prescribers sent ePrescriptions directly from their clinical
information system.
GPs can also receive alerts when the last repeat has been
dispensed and also script requests from pharmacies.
Pharmacies can scan scripts or repeats to call the information from the
prescription exchange service.
In the future this may become paperless.
New apps are allowing
consumers to order their repeats from
their chosen pharmacy using eTP technology.
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EMM in order, record & review Prescription and dispense records
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Screenshot of a sample dispense record
Copies of prescription and dispense records are now available in a consumer’s My Health Record
GPs and pharmacies using a prescription exchange service, and who are also registered for the national eHealth record system, can send prescription and dispense records to a consumer’s My Health Record.
My Health Record compares
prescriptions to their corresponding
dispenses. Clicking on the entry opens the detailed
records.
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Next section
Whether in hospital or community pharmacy, the dispensing systems and processes have already benefited from significant technology advances. Electronic transfer of prescriptions (eTP), barcode scanning and online claiming have helped drive efficiencies and make pharmacies safer.
EMM in dispensing Overview
EMM, a guide for healthcare providers 24
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Common problems in dispensing • Polypharmacy; increasing numbers of patients taking increasing numbers of
medicines. • Dispensing errors; including those caused by look-a-like and sound-a-like medicines,
transcription errors or prescription legibility. • Lack of information about patients comorbidities, concurrent medicines and allergies.
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EMM in dispensing Initiatives
EMM, a guide for healthcare providers 25
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There are a number of projects underway to help improve dispensing processes
Closed-loop dispensing Hospitals are implementing system to enable electronic orders to be sent directly to pharmacy systems
Better quality barcodes Work is underway to improve
the GTIN information (barcodes) that suppliers
share with electronic systems
Automated dispensing Robotic dispensing units are increasingly being installed in both acute and primary care
pharmacies
Structured content Australian Medicines Terminology enables standard unambiguous medicines naming as well as a unique identifier and machine
readable information
My Health Record Pharmacies can view information and contribute to the My Health
Record through event summaries and dispense records
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EMM in supply of medicines < back
EMM, a guide for healthcare providers 27
Recallnet allows for suppliers to issue
electronic notifications to health providers to recall
products that may be defective
Lifecycle of a product NeHTA supply chain
Locatenet is a global location number
directory that helps identify where products
are from
The National Product Catalogue (NPC) captures detailed
product information from suppliers to be
shared throughout the supply chain
As medicines are registered, a unique concept identifier, description and
supporting information is created in the
Australian Medicines Terminology (AMT)
There are a number of projects underway to improve the quality of data in the medicines supply chain
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EMM, a guide for healthcare providers 28
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EMM in medicines administration < back
EMM, a guide for healthcare providers 29
Electronic ward cabinets
Dose based prescribing Barcode
verified administration
Electronic reminders &
alerts Electronic medicine
administration records
EMM systems are being introduced in hospitals and aged care facilities to ensure safer, more efficient medicines administration
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EMM, a guide for healthcare providers 30
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Next section
Electronic medication
management
Monitoring misuse of
drugs
Medication incidents /adverse events
Adherence monitoring
Research and
analysis
Pathology results
EMM in ‘monitor for effect of medicines’
Monitoring medicines issued to patients to see if they are: • Effective • Tolerated • Used appropriately
is one of the major advantages of EMM systems. New systems are being implemented to facilitate: The monitoring of the sale, supply and
use of controlled drugs; Pathology reports shared in the My
Health Record; Dispensing records in the My Health
Record; and Better monitoring of adverse events and
allergies. EMM, a guide for healthcare providers 31
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There are now a growing number of remote monitoring
technologies that can help capture patient recorded data
This can then be shared electronically or during
consults.
Examples include inhaler adherence monitoring, tablet counters through to electronic
sphygmomanometers
EMM in ‘monitor for effect of medicines’
There are a number exciting initiatives to improve monitoring the effect of medicines – here are a few examples
EMM, a guide for healthcare providers s32
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Integrated vitals monitoring
An increasing number of acute care facilities are
integrating their monitoring devices with EMR systems.
This enables clinicians to monitor and record the
impact of medicines
Pathology Analytics & Dashboards
Antimicrobial Stewardship
Software
Home Monitoring & Wearables
Pathology is becoming more integrated in acute and primary care systems. Shared records, including My Health Record, will
also contain more results
This enables more sophisticated analysis and reporting to
facilitate better monitoring of medicines response
Acute and residential aged care facilities are now
introducing software to help support and monitor the
appropriate use of antimicrobials.
These solutions combine
EMM, pathology and decision support to optimise the use of
antibiotics
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EMM in continuity of care Overview
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Transitions of care are known to be a point of vulnerability for medication management. Whether this is a transfer within hospital department, at admission to, or discharge from hospital to home or residential care the presence of a curated medicines list will significantly improve the ability of the new healthcare professionals or teams to deliver safe, high quality care. Studies show that approximately 20% of patients experienced a significant delay in medicine administration upon arrival at the facility and that 12% of missed doses were considered high risk. Semple S, Roughead E. Medication safety in acute care in Australia: where are we now? Part 2: a review of strategies and activities for improving medication safety 2002-2008. Australia and New Zealand Health Policy 2009;6(1):24.
80% contained one or more discrepancies when compared with the discharge prescription; Only 50% of the changes to regularly scheduled medicines; Only 25% of the changes to medicines scheduled “as required”. Callen J, McIntosh J, Li J. Accuracy of medication documentation in hospital discharge summaries: A retrospective analysis of medication transcription errors in manual and electronic discharge summaries. International Journal of Medical Informatics 2010;79(1):58-64.
Discharge summaries Intervention at care transitions by family and care givers (facilitated by EMM) has been also been shown to reduce rates of hospital readmission and to improve patient confidence in medication self-management. Parry C, Min S-J, Chugh A, Chalmers S, Coleman EA. Further application of the care transitions intervention: results of a randomized controlled trial conducted in a fee-for-service setting. Home Health Care Services Quarterly 2009;28(2-3):84-99.
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EMM in continuity of care The role of the discharge summary
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Healthcare providers can now send e-Discharge summary documents via a secure messaging service. Typically this would be from a hospital to a GP. However it is also now possible to send discharge summaries to a consumer’s My Health Record. e-Discharge summaries are based upon a specification and should include:
– details about the patient; – overview of the episode of care or ‘event’; – summary of interventions; – diagnostic investigations including pathology test results.
There should also be detailed information about medicines including:
– current medications on discharge; – ceased medications on discharge.
Discharge summaries are important documents in handover and care transition. The ability to share these documents electronically and access them via My Health Record should help improve medicines management across care transitions. The NEHTA website has more information about discharge summaries
Screenshot of a sample e-Discharge summary
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What is happening nationally? What national work is being done to support implementation of electronic medication management?
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What is happening nationally?
EMM, a guide for healthcare providers 38
• Australian Medicines Terminology
• SNOMED CT-AU Terminology
• National reference sets including dose based prescribing
• Standards development for recording medicines
• Supply chain enhancements
• ePrescriptions
• My Health Record • Electronic transfer of
prescriptions • PBS and MBS
enhancements
• Safe display of medicines onscreen
• Tall Man lettering • eHealth safety • EMM implementation
guides
There are a number of national initiatives underway to support EMM. Click the logos below to visit the appropriate website to find out more about
that organisations activities in EMM.
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What is happening nationally?
EMM, a guide for healthcare providers 39
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The NT has been working with EMM systems for a number of years
in its hospitals and clinics. These solutions are now being expanded
and enhanced
Queensland Health are beginning to roll-out a full integrated EMM systems across a number of its
public hospitals as part of its iEMR program
NSW Health EMM program are working with Local Health Districts to introduce EMM,
improved supply chain and AMS systems into hospitals
ACT will be dramatically expanding the EMM systems in hospitals over the next 2
years; including new reconciliation, ordering, supply
and discharge solutions
Tasmanian hospitals have been working towards integrated EMM for a number of years. There are now
apps for discharge, reconciliation and decision support with full
administration being rolled out over time
Victorians have been benefiting from EMM systems for a
number of years, these systems are now being refined and
expanded
WA has been developing its EMM capabilities for
some time, including automated dispensing,
electronic recording and supply chain optimisations. There are a number of new
systems planned for the near future.
Several large eHealth programs in South Austrlia are
implementing EMM solutions, including automated dispensing and electronic ordering, supply
and administration
National EMM functional framework NEHTA has released a detailed functional framework that summarises all of the activities
underway with EMM in detail. Visit the NEHTA website for more information http://www.nehta.gov.au/news-and-events/news/815-emedications-management-
functional-framework-v1-0-march-2015-release
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EMM demonstrations for community prescribers and pharmacy practice
EMM, a guide for healthcare providers 41
There are a number of national initiatives underway to support EMM
click the logos to visit the appropriate website to find out more about that organisations activities in
EMM
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Glossary Term Acronym Description
Australian Medicines Terminology AMT The national terminology standard for the electronic description of medicines. The AMT provides an unambiguous description, unique identifier and important related attributes of medicines that can be understood by both humans and machines.
Systematized Nomenclature of Medicine--Clinical Terms
SNOMED CT-AU
SNOMED CT-AU is a subset of the international SNOMED CT terminology. It aims to provide an unambiguous description and unique identifier for medical terms, such as diagnosis, treatment and outcomes.
My Health Record My Health Record
Developed and operated by the Australian Government Department of Health, My Health Record is a shared electronic health record available for any Australian. Participating Health Providers can send and view a range of documents via the Record, either in their Clinical Information System, or via the portal at ehealth.gov.au.
Prescription exchange service PES These services enable prescriptions to be securely transmitted from GPs (or other prescribers) to participating Pharmacies.
Electronic transfer of prescriptions eTP A mechanism to electronically send prescription documents to pharmacies via a Prescription Exchange Service.
Clinical information system CIS The computer system or application used by clinicians as part of day to day practice to record information about patients and carry out activities related to the provision of healthcare.
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